An AIDS epidemic is sweeping through Madagascar’s high-risk populations, including gay men and sex workers. But a low detection rate means the statistics do not match the reality. EurActiv France reports.

One morning in November 2014, Lala started coughing up blood. His mother took him to a health centre in Madagascar’s capital Antananarivo, where the young languages student was diagnosed with tuberculosis.

“But under health centre protocol I was automatically offered an HIV test, which I accepted,” the young man said. The test came back positive.

“I knew that tuberculosis could be treated, but I thought I would be affected by HIV my whole life. I found it very hard to accept,” he said.

Only Lala’s boyfriend and his mother know that he is HIV positive. Today, he has finished his tuberculosis treatment and his HIV viral load in undetectable.

Lala still does not know how he came to be infected with the virus. “Maybe it is because I am a man who has sexuel relations with other men,” he said.

According to the UN, AIDS-related deaths and further infections are on the decline worldwide. However, NGOs worry that foreign aid will be cut because of the global economic crisis. EurActiv France reports.

Madagascar’s AIDS epidemic is highly concentrated in the country’s high-risk population: 15% of men who have sex with men (MSM), 7% of users of injectable drugs and, to a lesser extent, sex workers (1.3% in 2012) are HIV positive. Young people, some of whom belong to more than one of these groups, are at the highest risk.

Lala’s tuberculosis led to his infection being detected by chance. But for many MSM, gaining access to the appropriate prevention, screening and treatment is an uphill struggle.

Some do visit health centres that offer rapid HIV testing. “In general, MSM come here after being contacted by awareness campaigners. Sometimes they are given reduction coupons by the educators in charge of this awareness work, but the screening tariffs are always taylored to the person,” said Dr Raniriharisoa Voahirana Lalao, a health centre director.

“But they only come for screening once or twice. Worse still, many stop at the consultation stage and do not get tested,” Raniriharisoa said.

Prevention through awareness

Education workers are conducting a broad prevention campaign throughout Antananarivo, raising awareness among MSM about the use of condoms, as well as about regular testing. Trained and funded by the NGO Population Services International (PSI), which is active in a number of countries, these educators explain the basic precautions people can take to protect themselves.

“For example, I reassure them by explaining that the liquid on the end of a condom is not tap water,” said Balou, an HIV awareness worker. Madagascar’s water supply is so polluted that this seemingly unimportant detail can make the difference between people choosing to use condoms or not.

PSI focusses its actions on high-risk populations. “We have partnerships with the owners of nightclubs, brothels, bar hotels, etc.,” said Pierre Loup Lesage, a representative of PSI in Madagascar.

Educators make contact with members of the high-risk groups that frequent these places and encourage them to get themselves tested.

But the NGO is only active in 37 towns in Madagascar, “and we cannot raise awareness among all populations”.

An enormous statistical challenge

Beside the difficulties in educating high-risk populations, Madagascar also faces other challenges in its fight against AIDS.

According to the official statistics, the number of cases of HIV in Madagascar (both old and new) is relatively low. In 2014, just 0.3% of the population was recorded as carrying the virus.

This is a similar level to countries like Chili, Ireland and Laos. And far lower than other similarly-developed African countries like Niger (0.5%) or Mali (1.4%).

“But the figures for infected people do not reflect the reality,” the island’s Minister for Public Health Mamy Lalatiana Andriamanarivo said. The reason is simple: “only 12% of 15-25 year-olds use condoms, and 90% of the population has never been tested,” the minister said.

“The problem in Madagascar is that the population does not even know the disease. And people underestimate it,” he added.

Official estimates cite between 40,000 and 60,000 people living with the AIDS virus. And the available figures are shocking: only 1,300 people know they are infected, with just 900 receiving treatment in the whole of Madagascar.

The lack of reliable health statistics is certainly holding back the country in its fight against HIV, but coupled with its heavy dependence on international aid, this becomes a real handicap.

Some 90% of Madagascar’s health budget comes from international donors. And based on the low prevalence of HIV in the country’s official statistics, the generosity of many donors is waning.